HealthlinkOnline Application Form for Agencies

Please complete the form and click Submit. Fields marked with * are required.
If you have any problems please call (01) 8825606.

Agency Name:*
Address:*
Phone Number:*
Fax Number:*
Mobile Number:*
Email Address:*
 
Agency Staff Details
 Person One Details
Name:*
Position:*
Mother's Maiden Name:* (security & authentication)
PIN Code:* (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 
 Person Two Details show additional practice staff details hide practice staff details
Name:
Position:
Mother's Maiden Name: (security & authentication)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 Person Three Details show additional practice staff details hide practice staff details
Name:
Position:
Mother's Maiden Name: (security & authentication)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 Person Four Details show additional practice staff details hide practice staff details
Name:
Position:
Mother's Maiden Name: (security & authentication)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 Person Five Details show additional practice staff details hide practice staff details
Name:
Position:
Mother's Maiden Name: (security & authentication)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 Person Six Details show additional practice staff details hide practice staff details
Name:
Position:
Mother's Maiden Name: (security & authentication)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 Person Seven Details show additional practice staff details hide practice staff details
Name:
Position:
Mother's Maiden Name: (security & authentication)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 Person Eight Details show additional practice staff details hide practice staff details
Name:
Position:
Mother's Maiden Name: (GP only)
PIN Code: (enter a date which is easy to remember e.g. DOB (DD/MM/YYYY))
 
Hospital Details
Which Hospitals would you like to receive messages from:
All Live Hospitals
All Future Hospitals
AMNCH
Beaumont
Beacon
Cavan General
Connolly
Cork University Hospital
Ennis General
Euromedic Charlemont
Euromedic Cork
Euromedic Dundrum
Euromedic Kilkenny
Euromedic Northwood
Limerick Regional 		Letterkenny General
Loughlinstown
Louth County Hospital
KDOC
Mater
Mater Private
Mayo General
Merlin Park
Monaghan County
Mullingar
Naas
NorthEast Doc
NVRL
Our Lady of Lourdes, Drogheda
Our Lady's Hospital, Navan 		Portlaoise
Portiuncula
Roscommon County
ShannonDoc
Sligo
SouthDoc
St. James's
St. Joseph's, Nenagh
St. Michael's, Dun Laoghaire
St. Vincent's
Tullamore
UCHG
Waterford Regional
WestDoc
 
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Disclaimer
To all users of this service, please note that we are introducing the secure online neurology service to try and reduce patient waiting times for a neurological opinion. The advice given will be, by the very nature of such a service, wholly based on the referral received and thus cannot completely replicate the usual neurological consultation. The Department accepts responsibility for the advice given only on the basis of the information supplied. Should there be any doubts about that advice we would suggest referral in the usual manner.

If you wish to use Neurolink please tick this box indicating you have read the disclaimer from participating hospitals.